Croydon University Hospital has apologised to the family of a 52-year-old South Croydon woman after “procedural failures” before she to choked to death on a ham salad she should not have been fed, an inquest has heard.

During the hearing on Tuesday (June 26), director of nursing Michael Fanning told the family of Amanda House he was "genuinely sorry" for her tragic death.

While trying to assure “lessons have been learnt”, he confirmed two members of hospital staff had been dismissed after Ms House fatally choked on a 6cm by 5cm lump of ham she should not have been given, as her dietary requirements were for soft food only.

After being admitted to hospital at 5.30pm on Saturday, May 13 with respiratory failure, Ms House was intubated for 17 days and was said to be making steady progress before the incident on Sunday, June 18, 2017.

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Ms House went into cardiac arrest after choking on the ham, and passed away following seven failed rounds of CPR.

The court heard a catering hostess had admitted "making a mistake" by not double checking Ms House's dietary requirements when she was allowed to order a ham salad to eat earlier that day.

Mr Fanning said there had been "communication problems" when handing over patients to other teams and a lack of proper supervision at meal times.

The catering hostess told the inquest she had assumed Ms House was back on normal food as she was due to leave the hospital briefly for lunch with her family.

Croydon University Hospital (Image: Croydon University Hospital)

Born in Croydon, Amanda House had a history of heart issues dating back to 1986 as well as epilepsy, type 2 diabetes, septicaemia and arthritis while being a heavy smoker for about 34 years of her life, the inquest was told.

Before going to hospital she was staying at the Southleigh Community Mental Health Hospital on Brighton Road rather than her home in Heathfield Road.

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The inquest, held at South London Coroner's Court in Davis House, Croydon, heard evidence from 19 witnessess, including 15 members of staff from the hospital.

Senior Coroner Selena Lynch heard how a yellow form with Ms House’s dietary requirements had “gone missing” and not been found, which “no one has admitted taking” during an internal investigation, something she described as “a primary issue of safety”.

Peters Aremu worked for the Croydon University Hospital trust from 2010 (Image: Paul Martyniuk)

Ms Lynch acknowledged that most hospital staff witnesses present in Ms House’s Heathfield Two ward on the day of her death recalled seeing the yellow form, which is usually in a a visible location, except healthcare assistant Yvette Maxwell.

Earlier on the day of her death, Ms House went out for lunch with her family but was scheduled to have an evening meal back at the hospital.

Despite Ms House being on a soft food diet and recently coming off feeding tubes, catering hostess Cecilia Ayitey admitted ordering the ham salad with her.

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Ms Ayitey said: “Earlier she said she was being released to go off with her family and would want an evening meal. I gave her the menu and she ordered a ham salad.”

When answering questions from Lee Daniels, counsel for the House family, Ms Ayitey admitted she “made a mistake” by not checking Ms House's dietary requirements and added: “She said she was going out with family for lunch and I assumed she was eating normally again”.

The inquest also heard an apology from staff nurse Maria Dominguez who admitted she had been dealing with control drugs and other parts of her job at a time she was designated to be with patients for meal time, before she found Ms House suffering cardiac arrest.

South London Coroners Court, Davis House, Robert Street, Croydon (Image: David Cooke)

Ms Dominguez said: “I went to Ms House and asked if she had a nice day with her family. She said yes, was in bed at that time and sitting upright. She said yes. I noticed the ham salad and said ‘what is this, you’re supposed to be on a soft food diet' before witnessing her go into cardiac arrest."

Despite seven rounds of CPR by the hospital staff, she passed away at about 5.30pm.

Deputy ward nurse Elizabeth Dodoo, who was in charge at the time, said patient dietary requirements "would have been discussed” on handover but admitted hospital policy was not being kept to and did not know why Ms House’s dietary forms on three separate occasions had been signed off with the form incomplete without the correct information.

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She said: “There was a policy in place of what you should do rather than it being in good practice."

According to Mr Fanning, the hospital has since introduced a '10 steps to safe meal times plan' as a result of the incident.

He said: “I accept there was a failure to follow policy around meal times and safeguards. Specific date forms were left blank and yet signed off.

“There were communication problems at handover, no supervision at meal times as recommended and the wrong meals ordered.

“At Croydon and nationally there has been a focus on meal times to ensure staff’s priorities and safety nets have been put in place. As we have heard today the responsibility to make sure adequate food and medication is up to registered nurses.

"On Heathfield Two ward there was a lack of specific responsibility and I'm genuinely sorry it has taken this incident to build this particular practice. To say tragic is an understatement."

Speaking about what the hospital has done since Ms House's death, Mr Fanning said: "The system wasn't used consistently. A range of actions have been implemented at meal times to ensure it doesn't happen.

"We have put in place a whole number of additional measures. We are doing regular spot checks and speaking to staff more and asking questions so they know what is expected. We have moved our records to be electronically recorded for transparency and have set up a ward nutrition champion."

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After hearing all the evidence, Senior Coroner Selena Lynch is set to give her summary and verdict on Thursday (June 28) morning.

A Croydon Health Services NHS Trust spokesman said: “We have offered our sincere condolences to Mrs House’s family and we are truly very sorry for their loss.

“We conducted a thorough investigation into what happened on the day she died and have shared all of our findings with Mrs House’s family and the Coroner.

“A number of our staff have given evidence at the inquest to ensure the family have the answers they need and we can prevent such a tragic case occurring again.”

In a similar incident in 2014, an patient in his 70s who was supposed to be on a puree diet died a week after he was fed the wrong food, which was the most serious of three reported incidents in a matter of months at the hospital.

In the other incidents, a patient on a puree diet was fed a sandwich, and a man who was supposed to be nil by mouth was given soup, leading to serious breathing difficulties from which he later recovered.